Interview: Shona Robison MSP

As Scotland’s Public Health Minister, Shona Robison has a number of challenges at her door – our poor records on obesity, inactivity, tobacco and alcohol misuse, to name but a few – however, at the moment it appears to be the fraught relationships between the political parties in Scotland that are proving the biggest obstacle.

Robison, she professes, has long subscribed to the theory that “public health policies are at their best when they are bold and radical.” And yet as the current furore over the SNP Government’s attempts to introduce a minimum pricing policy for alcohol attests, thinking big is a poor match for smallminded party politics. For while Scotland has previously won international acclaim for forward-thinking policies such as the ban on smoking in enclosed public spaces, Robison fears such a feat might not have been possible in the current political climate.

“I’m not sure if as a minority government we were in a position of bringing forward the ban on smoking in public places that we wouldn’t be that far away from where alcohol is at the moment, to be quite frank,” she says.

She continues: “When that policy came forward it was enormously controversial and as the major opposition party at the time we came under enormous pressure to come out against it. I was the health spokesperson at the time and I decided that no, there could have been an opportunist position to have been taken there because there was a big lobby against it, but I took the position that it was the right thing to do.” Given the amount of evidence supporting the minimum pricing policy and the backing it has received from health professionals, academics, the police and fire services, Robison says she would have felt “deeply uncomfortable” as an opposition spokesperson maintaining that they were all wrong and she had it right by opposing the idea.

“It is the easiest thing in the world when you are in opposition to see your opportunity to have a go at the government of the day and I’m sure we all had our fair share of that when we were in opposition but I would like to think, particularly as we matured from the first session to the second session when we were challenged around things like the ban on smoking in enclosed public places, that we came up to the plate on that. So really, the challenge is for others to see the bigger picture.” However, she remains optimistic that a truce can be struck and that first step taken.

“The first step is the most difficult, to actually take the position of saying we know this is controversial but for public health reasons it has to be done, and at the time people said exactly the same stuff about the evidence around the ban on smoking in enclosed public places as they say about alcohol, exactly the same. ‘There is no evidence base, businesses will go out of business, it won’t work.’ We heard all of these arguments, exactly the same, but despite that people held their nerve and took the first step and now of course the second step is a lot easier because that step was taken. And that is why with alcohol, and I firmly believe the first step with alcohol is the most difficult step, but once that step is taken, further more radical measures on alcohol will become somewhat easier to take because you’ve made that first step.” The current Tobacco and Primary Medical Services Bill, which includes measures to ban tobacco displays and cigarette vending machines, has benefited from that first step being taken with the smoking ban, she says.

Now at Stage 3, Robison says she is very pleased with the Bill’s progress.

“I’m very happy. I think there has been some good work done with the Health Committee on this. Again, it has been about people setting aside differences and focusing on the issue, which shows it can be done when people have a will. I think it has been improved by the work the committee has done on proxy purchase and bringing tobacco sales law really more into line with alcohol sales law in terms of the penalties. So I think it is a good Bill.” Scotland’s legislative approach to tobacco control has been fairly exhaustive, and yet the problem persists. Is there another legislative step left to take with tobacco control beyond the current measures?

“I think what I would say is, I’m not sure it is necessarily all legislative options. I don’t think we can be complacent and rest on our laurels.

I don’t think that that is tobacco done and dusted. There will always be opportunities to further denormalise smoking to further close down any loopholes the tobacco industry might find to continue to drive smokefree Scotland. I’m sure that this is part of the journey; I don’t think it is the end of the journey.” What of calls to extend the ban on smoking in enclosed public spaces to private cars carrying young children, an idea that has already received the tentative support of Dr Laurence Gruer, NHS Health Scotland’s director of public health science, when he said in a recent interview in Holyrood magazine that such a step would potentially “make sense”?

While Robison says there are currently no plans to extend the smoke-free laws to private cars, the Scottish Government is conscious that private cars are now one of the main places for exposure of children to second-hand smoke.

“I know it has been done in other countries so I think I would want to see the evidence base before committing to going down that route,” she says.

“I also think the strength of the measures so far have been that there has been a good evidence base and we have been able to explain the public health reasons for taking such action. I think any further action there would have to be [a] strong public health gain beyond that of the individual because at the end of the day, tobacco is a legal product and there is no intention to ban it, therefore, you have to balance the public health measures with the right of an individual to be able to use that product, as long as in using it, [it] doesn’t affect other people. And that of course has been the strength of the measures so far as there has been a clear public health argument in that effect. I certainly am open minded to look at whatever other measures we might take but I would certainly want to see the evidence base of taking such a measure and what the outcome would be.” However, in addition to grappling with the immediate challenges posed by tobacco and alcohol misuse, Robison is also spearheading a significant body of work that is looking further ahead to impending demographic change.

GROS projections show that the number of over-65s in Scotland is projected to be 21 per cent greater in 2016 than in 2006 and 62 per cent greater by 2031; a 21 per cent and 81 per cent rise respectively is predicted for the over-75s age group; while the number of over-85s is expected to rise by 38 per cent by 2016 and by 144 per cent by 2031.

In 2007/08 an estimated 42 per cent of the total NHS Scotland expenditure was for over-65s, and assuming that admission to emergency hospital beds rises directly in line with demographic change, the Government anticipates a 24 per cent rise in beds – around 1,800 more – by 2016, which would mean Scotland would need to build three more general hospitals in the next seven years.

With such figures in front of us the scale of the challenge ahead is abundantly clear.

Robison readily concurs that reshaping the older people’s care agenda is a massive undertaking, with several workstreams already established to look at how we fundamentally redesign services for older people ahead of a public consultation next year.

For example, some of the workstreams have begun considering what do we need to do to have better community-based services to avoid people going into hospital, she says.

“There are still far too many older people going into hospital where that situation can be avoided if they have the right support at home. So a real focus on home care and reducing avoidable hospital admissions, looking at the use of things like telecare, service development, intensive home care.” The principle of reablement is another key theme, she adds, which she says is about maximising what people can do for themselves with the support of services.

While such work is taking a long-term view and planning for the future, there is also related work ongoing to address some of the more immediate challenges for the care of older people, such as the forthcoming Dementia and Carers’ strategies. The Carers’ strategy builds on work such as providing 10,000 extra respite weeks, she says, and for the first time will include a separate standalone document for young carers; while the Dementia strategy, Scotland’s first and a document that Robison describes as a “really important milestone,” will look at issues that need to be resolved within the next few years, such as the use of anti-psychotic medication in care homes and staff training.

And underlying all of this work, Robison says, is the aim for better integration between health and local government.

“Now that could take various forms and various models,” she says. “I think the days are over where there are separate teams doing separate things with different budgets.

We can’t afford that inefficiency and the bureaucracy and protectionism that goes on, and still goes on around some of these budgets. It basically should be about what is best for the older person.

“I think we’ve got a once in a lifetime opportunity to really get it right for the next generation of older people who will have a different expectation of what they want.” And should they expect to see Scotland’s flagship Free Personal Care policy in their future? While the tall poppy policy is often singled out as a target for expenditure cuts, Robison is resolute in her support for it and argues that another prize of getting the reshaping care for elderly work right is the sustainability of the policy into the future, she says.

“FPC is an enormously important, popular policy and one that has been one of the flagship policies of the Parliament, one of the successes of the Parliament,” she says, “and I very much want to protect it and make sure it is there embedded in the long term.” Sustaining the policy is something we can and must do, she says.

“There is going to be no going back on FPC from this government and, therefore, we have to make sure that in order to achieve that we make changes in the system that can deliver that.”